Wicked issues and constructive conversations in health and social care

Image via Screenrant

The Social Care Institute for Excellence is working with the Health Foundation and Institute for Government on a fascinating project about how “constructive conversations” can help with “wicked issues” in health and social care.

I was lucky enough to be invited to a discussion about the project and hear a wonderful summary of the literature on both constructive conversations and wicked issues from ICFI, and wanted to quickly reflect here two key parts of the useful information that was shared.

(I stress that the information below is taken directly from the really excellent work by ICFI, to whom all plaudits should absolutely go!)

First, what is a wicked issue?

The concept is taken from social planning (Rittel and Webber, 1973) referring to problematic social situations where: there is no obvious solution; many individuals and organisations are involved; there is disagreement amongst the stakeholders and there are desired behavioural changes. Public policy problems are ‘wicked’ (Clarke and Stewart, 1997) where they go beyond the scope of any one agency (e.g. health promotion strategies) and intervention by one actor not aligned with other actors may be counter productive. They require a broad response, working across boundaries and engaging stakeholders and citizens in policy making and implementation (Australian Public Services Commission, 2007).

Wicked issues therefore have the following typical characteristics:

  • Are multi-causal with connections to many other issues
  • Are difficult to define – so that “stakeholders understand the problem in different ways and emphasise different causal factors… The way the problem is approached and tackled depends on how it is framed, so there may be disagreement about problem definition and solution.”
  • Are socially complex – “Decisions about how to tackle them are unavoidably political, values based and may raise moral dilemmas. They cannot be tackled as technical challenges with scientific solutions; there is no point at which sufficient evidence will be gathered to make a decision.”
  • Require a whole system, multi-agency response – they do not sit within the control or authority of a single organisation, making it difficult to position responsibility.
  • Have no clear or optimal solution – they are not right or wrong, but better, worse or good enough
  • Have no immediate or ultimate test of ‘success’.

Against these characteristics, questions of social care, health, promoting disability equality, and public service reform are all obvious wicked issues.

Second, what is a constructive conversation?

The phrase “constructive conversation” itself is perhaps not well known, but its attributes are becoming increasingly familiar since they reflect much of what the approach to system leadership calls for.

A constructive conversation engages in what area known as “clumsy solutions”:

  • Questions not answers: seeking a deep understanding of the problem
  • Relationships not structures: engagement as the primary vehicle of change
  • Reflection not reaction: resisting the pressure for decisive action at too early a stage
  • Positive deviance not negative acquiescence: ignore, or look beyond, conventional culture and wisdom
  • Negative capability: the ability to remain comfortable with uncertainty
  • Constructive dissent not destructive consent: seeking consent is often destructive and illusory
  • Collective intelligence not individual genius: WPs are not susceptible to individual resolution
  • Community of fate not a fatalistic community: collective responsibility to underpin action which is likely to involve risk-taking
  • Empathy not egoism: seeking to understanding how other people see the problem, and the wider context”

As a result, a conversation is constructive if the following are in place:

  • A commitment to be open and honest
  • A conscious effort to foster and maintain trust
  • Clear information, provided at the right time
  • A focus on relationships not methods, underpinned by the goal of collaboration
  • Well-defined roles and clear expectations
  • The involvement of all stakeholders, fostering a whole-system approach
  • The ability and willingness to be flexible, wherever possible”

What a wonderful though subtle rejection of “heroic leadership” or CEO-itis this is, and what an obvious parallel with co-production it produces!

As I read through the slides of the summary on wicked issues and constructive conversations I found myself scribbling “YES!” and “Absolutely!” all the way through, so well did the findings tally with my feelings about what’s needed for change, especially in health and social care, and disability equality. They clearly tally with the ideas of system leadership and collective impact we’ve written about here before on many occasions (1, 2, 3). Though I could understand it if people were to tire of yet another set of terms that could be used and abused, for me the value of the above is in having something further to point to, consistent with what we’ve been talking about before, that further articulates the how I feel we need to go about change.


#SCIEroundtable on community-led social care

Image by Nigel Wedge on Flickr
Image by Nigel Wedge on Flickr

The Social Care Institute for Excellence (SCIE) yesterday hosted an event on community-led social care. It’s the first in a series of events they will be hosting over the coming months, and if this one is anything to go by the rest will be well worth attending.

It’s not unusual to have speakers at events make you stop and think. It is unusual, though, for every speaker and all subsequent contributors to share views that are of a consistently high quality, offer fresh insights, don’t fall back on lazy or repeated wisdom, and all of whom stick to time. Somehow, though, that’s what was managed yesterday!

It wouldn’t do justice to the richness of the discussion for me to attempt to summarise what was talked about. Further details will, I think, be shared; but here are 3 things I particularly enjoyed in yesterday’s discussion.

  1. We must spend more time and effort thinking about “scaling across” instead of scaling up. Another way of thinking about this is about spread rather than size per se. This reflection came from people recognising that approaches which are working may work precisely because their characteristics work at a certain scale. By changing the scale you then affect the characteristics. Rather, then, than fundamentally changing the size (through scaling up) the smarter thing to do is think how to replicate (scale across, or spread).
  2. The ingredients of what makes stuff work are, by now, relatively familiar (though by no means regularly recognised or understood). These include trust, good relationships, good leadership at all levels, a shared vision etc. But more than this, the way in which these ingredients are brought together – the recipe – matters just as much. What’s more, the recipe may change from area to area, and whilst the ingredients are necessary, they aren’t sufficient. This leads to the idea (and switching metaphors) of creating an eco-system in health and social care (say), rather than just a system. This gives a better view of the range, diversity and strength of connections needed between all parts of the system, as well as thinking about what those connections are between.
  3. Paul Streets from Lloyds Bank Foundation shared what they call the “3 tyrannies” of commissioning: specifications, standards and scale. I shall be liberally repeating this!

For what it’s worth, my own reflection was on this idea of the “deficit of candour” in public services. Whilst there aren’t honest conversations about what public services can and can’t achieve in terms of people’s expectations and what they’re willing to pay for them, it becomes harder to create the conditions in which an eco-system could flourish. For me, one way of bridging this is by highlighting what rights people have: if people are equipped with this knowledge, not only will it help to rebalance the existing distribution of power between people and professionals, but also help people to think how they themselves can use their identity and capabilities to contribute themselves to the eco-system.

Thanks to everyone involved in yesterday’s stimulating debate, and thanks for SCIE for organising such a great session. The hashtag for the roundtable is #SCIEroundtable.

#Coproduction = win (and Bill Shankly)

It was great to be at the launch of SCIE’s excellent new resources on coproduction today.  The resources are here and well worth a look through (including two great videos in Have I Got News For You style – 1, 2).

Here are 5 thoughts/reflections from the day and wider conversations on Twitter.

1. Quite a lot of people get hung up on the definition of coproduction. I find this takes up valuable time that could be used figuring out how coproduction can be a very effective means by which we change public services and the role real people play in this. It may be easier to agree on what coproduction isn’t (clue: two public sector professionals from different organisations meeting together isn’t coproduction)

2. The following question was posed by none other than Lord Michael Bichard (see point 3): What do we need to do to get those people/organisations who don’t get coproduction to see its value and use it? Of all the things that can be done, I think the best is to equip real people with (a) the drive/expectation that they can be part of the way in which public services are designed and delivered; and (b) the evidence that coproduction works with which to convince intransigent others. Creating this demand won’t be sufficient, but it is absolutely necessary.

3. Both SCIE’s Chair (Lord Michael Bichard) and Chief Executive (Tony Hunter – who hasn’t even officially started yet) were there today – a fine indication of both SCIE’s commitment to coproduction and the importance of coproduction more generally.

4. It was noted there wasn’t a session dedicated to coproduction at NCASC (notwithstanding the excellent way TLAP presented their work). There should have been.

5. Coproduction has come a long way, but we all have to work together to ensure it goes much, much further. There is great evidence and practice that coproduction works and is a means by which the immense challenges facing public services – not just in social care and health, but all services – can be collectively approached and solved (see, for example, the excellent Coproduction Practitioners Network for lots of case studies etc.).

As a final thought, I hope you won’t mind me paraphrasing Bill Shankly. Some people believe coproduction is a matter of life and death. I can assure you it’s much, much more important than that.

Social work practices: pilots, pioneers and DPULOs

I blogged a while ago on the Social Work Practice pilots that the Department of Health proposed last year. This was exciting for me, since the benefits of social work practices are almost exactly the same for the benefits that accrue from disabled people’s user-led organisations (DPULOs).

Indeed, I hoped that some DPULOs would be involved in the delivery of the Social Work Practice pilots.

And, indeed, they are. The document embedded at the bottom of this post is a summary I’ve created of all of the Social Work Practice pilots, and includes two in particular – Birmingham and North East Lincolnshire – that are explicitly working with DPULOs.

The good news doesn’t end there. SCIE has recently announced a further 10 Social Work “Pioneer” projects – essentially the same thing as Social Work Practices, but just starting a bit later.

The full press release is here. What’s particularly exciting about this is that a further two sites – another in Birmingham and one in York – are directly involving DPULOs.

This is fantastic, and I’ll share relevant learning and information as the Social Work Practices and Pioneers move forwards.